LTC Bullet: LTC Almanac Update

Friday, January 4, 2019


LTC Comment: We’ve updated the “Almanac of Long-Term Care” in The Zone. More on the LTC Almanac and today’s update after the ***news.***

*** TODAY'S LTC BULLET is sponsored by Claude Thau, whose revolutionary “Range of Exposure” tool projects clients’ likelihood (joint for a couple) of spending $100,000; $250K; $500K or over $1,000,000 on LTC, based on their personal characteristics, and estimates how much of their cost in each range would be covered by various traditional or linked insurance designs. He also offers other ways to educate and help clients make informed final decisions in 15-20 minutes! Change work-site LTCi from a series of proposal deliveries to an interactive consultation! Claude is the lead author of Milliman’s annual Broker World LTCi Survey & a past Chair of the Center for Long-Term Care Financing. You can reach him at 913-403-5824 or ***

*** IMAGINE THE POSSIBILITIES, but do it quick. Early Bird Registration Discounts for ILTCI 2019 end this coming Thursday, January 10. The 19th Annual ILTCI Conference - March 24-27, 2019 convenes at the Sheraton Grand Chicago. If you’ve been to this annual convocation before, you know it is a top quality industry meeting. If you’re new, get ready for the best presentations and networking in the LTC insurance business. This year’s theme, “Imagine the Possibilities,” expresses perfectly the LTCI industry’s amazing persistence, resilience and creativity in the face of extraordinary challenges. See you there! ***

*** MOVIE NEWS: Ross Schriftman’s film, “My Million Dollar Mom,” won Best Drama at the Tampa Bay Underground Film Festival. Find the press release including seven nominations, a picture and a video with the award here:

The film focuses on the challenges families face when a loved one has dementia and is inspired by Ross’s true story. The value of long term care insurance is also highlighted. Congratulations! ***



LTC Comment: Center members know and appreciate our "Almanac of Long-Term Care" in The Zone, our password-protected website.

*** SPECIAL: We are making access to The Zone, including the "Almanac of Long-Term Care," free for two weeks—today through Friday, January 18, 2019. To access this introductory peek into The Zone, go to and use the following case-sensitive user name and password: UN: IntrotoZone / PW: FreeTrial. Like what you see? Then join the Center for Long-Term Care Reform here. Or contact Damon at 206-283-7036 or ***

The LTC Almanac is divided into 11 sections: 

Aging Demographics
Unfunded Liabilities--Social Security, Medicare, and Budgets
Long-Term Care
Long-Term Care Financing
Long-Term Care Insurance
Reverse Mortgages
Long-Term Care Providers
Medicaid Planning  

Each section is divided into sub-sections and under each sub-section we provide a list by date of the most important reports and articles published on the topic, usually with a few highlights and sometimes with analysis.

The Almanac of Long-Term Care is a great way to find statistics you need quickly or to get current on topics you need to know the latest information about.

The Zone and the LTC Almanac are for Center for Long-Term Care Reform members only, except during the current free trial offer. Join the Center here: Call or email Damon at 206-283-7036 or He can give you a user name and password to open up The Zone even before your dues payment arrives. Individual annual memberships are $150. Premium memberships with access to our “Clipping Service” start at $250. Premium Elite and “Regional Representative” membership (if you qualify professionally) are $500. Corporate memberships with many extra benefits start at $1,000. See our "Membership Levels and Benefits" schedule here.

Caveat: With time, some hyperlinks go bad. In a huge document like the "LTC Almanac," we can't keep all the links current all the time. If you find a bad link, but want to get to the material, contact us. We often have an electronic copy of the document and we can usually find a current live link. We'll also fix the link in the LTC Almanac so it will be current again for others.

Suggestion: Read through the following update to stay current on new resource materials. Then browse the full LTC Almanac at your leisure. When you need a quick fact or the latest research on a particular topic, you'll know right where to go. Enjoy.


Chapter 1: Aging Demographics

AARP's Across the States--Long-Term Care Profiles

Excellent source for state-by-state data on "many facets of long-term care and independent living in each state and the District of Columbia." Updated usually every two years: 2002, 2004, 2006, 2009, 2012, now 2018.

Across-the-states 2018 0918 URL:

9/4/2018, “Nursing home resident numbers decreasing, while quality varies, new AARP analysis notes,” by Marty Stempniak, McKnight's LTC News

Quote: “Nearly every state in the country (46) saw a decrease in the number of nursing home residents between 2011 and 2016, according to a new analysis published by AARP. All told, about 1.3 million Americans lived in nursing facilities on an average day, occupying about 81% of the 1.7 million beds available, the retired persons interest group noted last week in its 24th annual ‘Across the States’ report, providing a snapshot into long-term care across the country. … You can read the entire free report here, and find specific state-level reports here.” (Emphasis added.)

LTC Comment: This is our second clipping of the day reporting on AARP’s latest “Across the States” report. Check it out and watch for our analysis in the weeks ahead.

9/4/2018, “Assisted living supply, charges vary widely among states, new AARP report shows,” by James M. Berklan, McKnight's Senior Living

Quote: “The District of Columbia ($80,400) and Missouri ($32,400) represent the ends of the spectrum for average annual charges for private-pay assisted living in a new report released by the AARP. Meanwhile, the supply of assisted living and residential care units among various states showed even more divergent statistics: Oregon led with 121 units per 1,000 people, whereas Louisiana was last at 20 per 1,000. The figures are included in the newly released AARP Public Policy Institute's 2018 edition of ‘Across the States/Profiles of Long Term Services and Supports.’

LTC Comment: AARP stopped publishing this very useful report for several years. It’s good to see it back and we’ll offer detailed analysis in a future LTC Bullet.

We made good on that promise with LTC Bullet: Long-Term Care Across the States, Thursday, September 27, 2018

Expenditures of the Aged

NBER on The Lifetime Medical Spending of Retirees 0518 URL:

The Lifetime Medical Spending of Retirees
John Bailey Jones, Mariacristina De Nardi, Eric French, Rory McGee, Justin Kirschner
NBER Working Paper No. 24599
Issued in May 2018, Revised in July 2018
NBER Program(s):Health Care, Health Economics, Public Economics
Using dynamic models of health, mortality, and out-of-pocket medical spending (both inclusive and net of Medicaid payments), we estimate the distribution of lifetime medical spending that retired U.S. households face over the remainder of their lives. We find that households who turned 70 in 1992 will on average incur $122,000 in medical spending, including Medicaid payments, over their remaining lives. At the top tail, 5 percent of households will incur more than $300,000, and 1 percent of households will incur over $600,000 in medical spending inclusive of Medicaid. The level and the dispersion of this spending diminish only slowly with age. Although permanent income, initial health, and initial marital status have large effects on this spending, much of the dispersion in lifetime spending is due to events realized later in life. Medicaid covers the majority of the lifetime costs of the poorest households and significantly reduces their risk.
You may purchase this paper on-line in .pdf format from ($5) for electronic delivery.

LTC Comment: We analyzed and critiqued this paper in LTC Bullet: How and How Much Medicaid Reduces Lifetime Medical Spending for Affluent Retirees, October 10, 2018.


Chapter 3: Unfunded Liabilities--Social Security, Medicare, Pensions and Budgets

National Health Expenditures

Health Affairs on National Health Expenditures for 2017 URL:
NHE for 2017 URL:

See also: LTC Bullet: So What If the Government Pays for Most LTC?, 2017 Data Update, Thursday, December 13, 2018

Unfunded Liability Estimates

AEI on The-2018-Medicare-Trustees-Report 0718 URL:

7/9/2018, “The 2018 Medicare Trustees Report: Fiscal and Policy Challenges,” by Joseph Antos and Robert E. Moffit, AEI Economic Perspectives

Quote: “Medicare’s financial outlook has deteriorated in the past year, according to the latest annual report by the program’s trustees. The Medicare Hospital Insurance trust fund is projected to be depleted in 2026, three years earlier than estimated in last year’s report. That understates the policy challenge. Every year, the program relies more on general revenues to cover its costs. In total, Medicare will receive $324 billion in general revenues this year. That will more than double by 2026. Prompt action is needed to put Medicare on a sound financial footing.”

LTC Comment: Trenchant analysis by two of the best health policy analysts I know.

Don’t Count on Social Security or Medicare

Social Insurance and American Health Care -- Principles and Paradoxes, by Theodore R. Marmor 11-29-2018 (3) URL:

Journal of Health Politics, Policy and Law, Vol. 43, No. 6, December 2018
DOI 10.1215/03616878-7104419 _ 2018 by Duke University Press

We analyzed and critiqued this article in LTC Bullet: Venezuela, Yale and Long-Term Care, December 7, 2018


Chapter 6: Long-Term Care Financing


NBER on LTCHs 0818 URL:

8/2018, “Long-Term Care Hospitals: A Case Study in Waste,” by Liran Einav, Amy Finkelstein, Neale Mahoney, National Bureau of Economic Research

Quote: “There is substantial waste in U.S. healthcare, but little consensus on how to identify or combat it. We identify one specific source of waste: long-term care hospitals (LTCHs). These post-acute care facilities began as a regulatory carve-out for a few dozen specialty hospitals, but have expanded into an industry with over 400 hospitals and $5.4 billion in annual Medicare spending in 2014. We use the entry of LTCHs into local hospital markets and an event study design to estimate LTCHs’ impact. We find that most LTCH patients would have counterfactually received care at Skilled Nursing Facilities (SNFs) – post-acute care facilities that provide medically similar care to LTCHs but are paid significantly less – and that substitution to LTCHs leaves patients unaffected or worse off on all measurable dimensions. Our results imply that Medicare could save about $4.6 billion per year – with no harm to patients – by not allowing for discharge to LTCHs.”

LTC Comment: This is the abstract for the full paper which is available through NBER here: Could treating high-acuity LTCH patients in SNFs save money without tipping the delicate balance of high Medicaid dependency and low reimbursement against quality? I’m very dubious.

8/27/2018, “How to Tame Health Care Spending? Here’s a One-Percent Solution,” by Margot Sanger-Katz, New York Times

Quote: “The researchers concluded that the health care system could probably save a lot of money — around $5 billion a year — by paying the long-term care hospitals the same prices that are paid to skilled nursing facilities, the places that most long-term patients end up in when there is no long-term care hospital nearby. If they’re right, the savings would probably be in the 1 percent range. … The scholars involved in the project know that they are not the first group to think small. The sort of deep and narrow investigations they are undertaking have long been the focus of groups like the Medicare Payment Advisory Commission, a group that recommends changes to Congress and that had even flagged long-term care hospitals for overhaul years ago. Washington policymakers and think tanks have long assembled briefing books of options to help them nip and tuck dollars out of government health programs.

LTC Comment: More on the NBER research we highlighted earlier today, this time in the New York Times. If saving a measly $5 billion is no longer beneath the dignity of the economics profession, maybe they should reconsider our analysis and proposal: Save Medicaid LTC $30 Billion Per Year AND Improve the Program (2011).


Chapter 10: Medicaid

Medicaid Financing and Burwell Data

8/23/2018, “Don't Blame Older Adults For Big Increases In Medicaid Spending,” by Howard Gleckman, Forbes

Quote: “Is the growing need for long-term supports and services (LTSS) by older adults driving big increases in Medicaid spending? Not according to a new study by Don Redfoot and my Urban Institute colleague Melissa Favreault. Indeed, they found that while Medicaid enrollment and expenditures for older adults grew in recent decades, it had far less effect on the program than increases in other Medicaid populations, especially younger people with disabilities. Older adults accounted for only about 13% of Medicaid spending increases from 1975 to 2011. … What did account for the relatively modest boost in Medicaid spending on older adults? … First, the asset test that helps determine financial eligibility for Medicaid is not indexed for inflation, and its income test is tied to a relatively slow-growing inflation factor. For instance, unmarried older adults generally are barred from enrolling in Medicaid if they have non-housing assets that exceed $2,000—a limit that has not changed since 1989. Thus, as the wealth of many older adults is increasing, the asset test is not and the percentage of seniors eligible to enroll in Medicaid is shrinking.

LTC Comment: More double talk and statistical prestidigitation from the usual suspects. The fact that ObamaCare policies spiked Medicaid costs mostly for new, young, able-bodied recipients doesn’t reduce, rather it increases, the future medical and LTC financial liability from the age wave which is just now starting to hit in earnest. The flat Medicaid asset test of $2,000 means nothing, because exempt assets are virtually unlimited, countable assets are easily convertible to exempt assets, and Medicaid planners still wave magic legal wands to make any additional wealth disappear. This research assuages concern about entitlement spending on the elderly in order to encourage more of the same. That’s a very risky prospect a decade or so before the bottom falls out of Medicare, Social Security, and Medicaid and boomers start turning 85, the age at which medical and long-term care costs explode.

KFF on Medicaid Enrollment and Spending 1018 URL:

10/25/2018, “2019 Will Be ‘Year to Watch’ for Medicaid as Long-Term Care Drives Spending,” by Alex Spanko, Skilled Nursing News

Quote: “Increases in long-term care costs contributed to an overall boost in Medicaid spending during fiscal 2018, and a leading health policy non-profit warns that 2019 could be a pivotal year for the program. ‘FY 2019 will be a year to watch how Medicaid’s role evolves on the ground in the 50 states and D.C.,’ the Kaiser Family Foundation (KFF) wrote in its annual report on Medicaid enrollment and spending, released Thursday.”

LTC Comment: Medicaid LTC spending growth, overshadowed for years by the rapid expansion of able-bodied ObamaCare recipients, is once again assuming the role of key revenue driver. And you ain’t seen nothin’ yet!